| Anthem Blue Cross (HMO, PPO, EPO) |
| Inlyta (axitinib) |
| Drugs for Cancer : Drugs for Cancer |
- Kidney Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of Clinical Pharmacology;NCCN Guidelines
ECOG Score Requirement Included in Policy: N/A
Policy Includes Reference to Coverage for Non Clear Cell Histology: No
If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
Concomitant Use With: 1 of Bavencio;Keytruda
Thyroid Carcinoma:
Duration: 1 year(s)
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Prior Authorization: Kidney Cancer:
Documented Diagnosis: Yes
Duration: 1 year(s)
Thyroid Carcinoma:
Duration: 1 year(s)
- Quantity Limit: 6 tablets per 1 day(s).
- Step Therapy: Thyroid Carcinoma:
ST Single Brand
- PA Applies
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